Table of contents

Introduction

The Heads of Workplace Safety Authority (HWSA) initiated a national intervention and compliance campaign in 2008 called Safe steps – Manual handling, slips and trips in hospitals. It recommended a national focus for central sterilising supply departments (CSSDs), to ensure implementation of control measures that reduce the risks associated with manual tasks. It also recommended particular attention be paid to the design of containers, handling of loan sets, use of lifting equipment, work area design, psychosocial issues, and liaison with equipment suppliers and building designers.

As a result of these recommendations, SafeWork NSW formed a national working party and undertook further research, which included state-wide inspections of CSSDs, courier services and surgical equipment suppliers. The inspections found that transporting and handling of road cases, tubs and surgical instrument trays presented a significant risk, with serious implications across these industry sectors.

This guide provides practical guidance for designers, manufacturers, suppliers, couriers and users of surgical instrument set transport cases, and outlines their obligations when transporting and handling the cases and their contents.

An industrial design expert was engaged to design a transport case that, when used in conjunction with this guide, would assist with national work health and safety legislative compliance.

Scope

This guide provides advice on the design, manufacture, supply, transportation and use of surgical instrument transport cases and their contents, with particular emphasis on safe design. Handling of this equipment is addressed through workplace design and safe work practices, involving the designer through to the end-user in the hospital. The guide also addresses the obligations of duty holders who are associated with the handling of these cases and their contents.

Surgical instrument trays less than 300 mm long are not required to be transported in the surgical instrument transport cases described in this guide. The design of tubs is not addressed within the scope of this guide. Tubs should only be used to transport prostheses and/or other lightweight surgical equipment not described in this guide.

Definitions

Consignment sets/long-term loaners – surgical instrument sets and implant prosthesis sets that are owned by the supplier and remain at the hospital on long-term contract.

Road case – a wheeled case that is currently used to house surgical instrument sets and/or medical supplies for transportation. (Under the new system, as described in this guide, these cases will be phased out and replaced by new surgical instrument transport cases).

Slip sheet – a divider between the surgical instrument outer containers that facilitates easy removal and insertion of contents.

Surgical instrument inner tray – a tray that contains surgical instruments, which is usually housed in an outer container.

Surgical instrument set – a set of instrument trays used in surgical operations.

Surgical loan kit – a combination of fully-laden surgical instrument transport cases and tubs for loan to hospitals for a surgical operation. The kits are typically returned to suppliers after surgery, unless retained on long-term consignment.

Surgical instrument transport case (new case as described in this guide) – a case used to house surgical instrument sets and/or medical supplies for transportation.

Tub – a top-opening container that is used to house surgical instrument sets and/or medical supplies for transportation. Under the new system, as described in this guide, tubs will only be used to house surgical implants.

Design principles

Work health and safety legislation places obligations on designers to identify hazards and control the risks associated with the design, manufacture, supply and use of equipment. The designer must, where reasonably practicable, design-out any risks associated with the use, handling and transportation of the following equipment.

Surgical instrument transport case

The surgical instrument transport case, used to transport surgical instrument trays and medical supplies, should be strong, durable and made from lightweight weatherproof material that minimises the potential for contamination. The case should protect the contents and minimise liquids, dust and contaminants from entering the case. The external and internal surfaces should be easy to clean and maintain.

The case should be designed to:

be end-opening for improved access when packing and unpacking trays, and aligned to open in the same direction. Doors and associated locking mechanisms should allow clear and easy access to the contents of the case and ensure the contents are secure during transportation

be securely stacked and transported on an appropriately designed wheeled platform

allow a tub to be securely stacked on top during handling and transportation

allow suitable signage and labelling to be prominently displayed

allow a mechanical aid to raise a single case or stack to a suitable working height

allow the contents (eg trays and associated equipment) to be removed and inserted without lifting, excessive force or awkward posture

allow slip sheets to be located between trays and securely retained within the case

Slip sheets

Slip sheets should be made of a material that is easy to clean and minimises friction. They should be located between trays and securely retained within the case, yet able to be removed when required.

Recommended design specifications1

Surgical instrument transport case assembled components

Recommended design specificiations2

Surgical instrucment transport case individual components

Wheeled platform

The wheeled platform used to move cases and tubs should be strong, durable and made from lightweight weatherproof material that minimises the potential for contamination.

The platform should be designed to:

be easy to clean and maintain

allow for secure location of the stacked cases and tubs on top of the platform

ensure the stack is stable and secure when moved

allow it to be locked to the bottom case when required

allow a mechanical aid to raise the wheeled platform and stack of cases to a suitable height

allow a mechanical aid to raise a single case or cases from the wheeled platform when required

support the maximum safe working load of the stack

The platform should have at least two multi-directional wheels, to ensure ease of movement and steering. The wheels should include a braking mechanism and conform to relevant standards. To determine the most appropriate wheels, consider the following factors:

terrain

durability

vibration

manoeuvrability

safety

Surgical instrument trays

Surgical instruments fit into specifically designed surgical instrument inner trays which are frequently housed in surgical instrument outer containers. The majority of Australian suppliers do not necessarily have control over the design of trays and containers, however, where reasonably practicable, the design principles set out in this guide should be followed.

Trays and containers protect instruments from damage during transportation and set out the instruments in a logical manner for surgery. They should be made from lightweight, durable material that can be cleaned and sterilised. Trays and containers should easily slide into and out of an end-opening case.

Tray and container handles should be designed to:

allow fully-laden trays to be safely handled

withstand cleaning and sterilisation

retain structural integrity

be easily accessible when trays and containers are inserted or removed from the case

This guide recommends that fully laden individual inner trays, where reasonably practicable, should preferably weigh up to 5kg and not exceed 7kg.

Safe use and handling principles

The loan kit area should be designed to eliminate or minimise manual tasks. In addition, every activity involved in surgical loan kit handling must be evaluated by each facility and courier organisation, and action taken to eliminate or minimise risks associated with all hazardous manual tasks. This will assist with safer, more efficient and cost-effective work processes.

All equipment should conform to relevant work health and safety legislation, this guide or an equivalent level of safety. Information on the safe use and handling of kits should be provided at the point of supply/use. Equipment should be regularly inspected and maintained to ensure it is able to be used in a safe and appropriate manner, as set out in this guide.

Communication strategies should be in place to minimise the number of manual tasks and ensure safe work procedures are effective. A systematic process should exist between suppliers, couriers and hospitals regarding the status of kits. The process should include:

coordinated receipt/delivery protocols (how, when and where)

appropriate internal and external contacts

suitable mechanical-handling equipment that is available at all points of the process

effective delivery and scheduling contractual conditions

A surgical loan kit handling process flowchart has been developed to provide a step by step overview of all activities involved in this process. In addition, tools have been developed to support key work processes for suppliers, couriers and hospitals, and are available as appendices.

Surgical loan kits handling process

Suppliers

As a supplier, designate a person to be responsible for coordinating the loan kit handling process. Document procedures for all tasks related to handling and processing of kits, and ensure all procedures follow health, safety and hygiene standards.

Effective communication is essential when coordinating the receipt and despatch of kits. Prepare a schedule of all receipts and despatches that includes the number of deliveries and the type of kits used, together with appropriate contact details for the hospitals and couriers.

Fully laden individual inner trays, where reasonably practicable, should preferably weigh up to 5 kg and not exceed 7 kg. Loaded cases should remain on their platform at all times for ease of use and movement. For stability, heavier cases should be positioned at the bottom of the stack. Tubs can be placed on top of the stack of cases during handling and transport. The stack should not exceed 1350 mm in height and the combined weight of the stack should not exceed 80 kg. Store cases and wheeled platform in a safe and secure place when not in use.

Use clear, self-explanatory signs and display them prominently on the side of each case (include your company name, the gross weight of each case, and any other relevant information). Ensure the case carrying the loan kit documentation is clearly identified and remove any old signage and labels. Cases and platforms should be thoroughly cleaned and maintained on a regular basis.

The loan kit area should be configured to eliminate or minimise the risks associated with manual tasks. This should include:

a designated area with adequate floor space for the systematic packing and unpacking of kits and the use of lifters and associated mobile equipment

designated holding and storage areas with adequate floor space

adequate access and egress with level non-slip floor surfaces

a work area that optimises work flow and minimises lifting and double handling

mechanical lifters and height adjustable work benches with fitted rollers

associated equipment (eg conveyors and trolleys) to assist with handling and movement

Couriers

As a courier, follow safe working procedures when loading and unloading your vehicle, ensuring that:

vehicles are fit for purpose

loads are safely secured

mechanical aids are fitted to vehicles (eg tailgate lifters). Where this is not reasonably practical, use mobile lifters and ramps

stacks are kept in their original configuration

Ensure that contractual arrangements are in place with all other parties. These arrangements should include:

a stipulation that transport cases are not manually lifted in or out of courier vehicles

designated loading and unloading areas

timely and effective despatch and receipt procedures

designated delivery and collection points

Tailgate lifters

Vehicles can be modified to ensure easy unloading and lading of transport cases.

Modifying a vehicle with a tailgater lifter device is the preferred option where reasonably practical.

All tailgate lifters should be fit for purpose and fitted by a competent person.

The modified vehicle has a floor and tailgate which lower to the ground to enable loads to be wheeled on and off via the ramp.

This type of vehicle will eliminate the need to manually lift cases during loading and unloading.

Mobile lifter

Mobile lifters may be used to reduce the risk of musculoskeletal injury when loading or unloading transport cases in and out of vehicles.

Ramps/skids

When purchasing a ramp or skids, ensure that:

the length and width allow for safe loading and unloading of kits

the weight does not pose a risk

they can be fitted and removed easily

they allow safe and smooth movement of wheeled stack when loading and unloading vehicle

they are stable and secure when in use

they can be stored and secured in the vehicle when not in use

Hospitals

All hospitals should have a CSSD manager who designates a staff member/s to be responsible for the loan kit handling process. Safe operating procedures should be in place and displayed clearly for all tasks related to the handling and processing of kits. All procedures should follow health, safety and hygiene standards.

Designated areas should be provided for the receipt/despatch of kits with adequate work space allocated to pack and unpack the kits. Cases should remain on their platform at all times for ease of handling and transportation, and should be stored in a safe and secure area when not in use.

Effective communication is essential when coordinating the receipt and despatch of kits. This should include receipt/despatch schedules, the number of deliveries and type of kits being used, and appropriate contact details for suppliers and couriers. Hospitals should ensure that kits are returned in a similar configuration and in line with designated weight restrictions (eg not more than 80 kg).

The loan kit area should be configured to eliminate or minimise the risks associated with manual tasks, including:

a designated area with adequate floor space for the systematic packing and unpacking of kits, including the manoeuvring of lifters and associated mobile equipment

designated holding and storage areas with adequate floor space

adequate access and egress with level non-slip floor surfaces

a work area that optimises work flow and minimises lifting and double handling

mechanical lifters and height adjustable work benches with fitted rollers

mobile equipment to assist with equipment handling and movement

Further information for hospitals on recommended floor areas can be found in the Australasian Health Facility Guidelines, Revision V 4.0 (16 December 2010). Part B of the Guideline covers Health facility briefing and planning. Visit healthfacilityguidelines.com.au to view the guidelines.

Equipment

Seek advice from a competent person to ensure that new and existing equipment is fit for purpose. Equipment should be trialled prior to purchase.

Mobile lifter

When purchasing a mobile lifter, ensure that it is compatible with the work environment, fit for purpose and:

has a lifting plate/tines that maintain a horizontal service when under load

manoeuvres easily in a restricted workspace

does not create further risk when operated

has a safe working load of 100 kg or greater

has appropriate castors with braking capacity

accesses the platform directly from floor level

lifts to at least 1000 mm above floor level

has a smooth and efficient action, with a powered lift mechanism that is easily accessible

lifts and lowers stack securely and safely

can lift a single case or tub when required

can be easily cleaned and recharged

Fixed lifter

When purchasing a fixed lifter, ensure that it is compatible with the work environment, fit for purpose and:

has a lifting plate/tines that maintain a horizontal service when under load

does not create further risk when operated

has a safe working load of 100 kg or greater

can be fixed to a wall or mounting frame

accesses the platform directly from floor level

lifts to at least 1000 mm above floor level

has a smooth and efficient action, with a powered lift mechanism that is easily accessible

lifts and lowers stack securely and safely

can be easily cleaned and recharged (where applicable)

Adjustable work bench

When purchasing an adjustable work bench, ensure that it is compatible with the work environment, fit for purpose and:

can accommodate multiple instrument trays

can be adjusted between 750 mm and 1150 mm from floor level

has rollers fitted at loading and unloading points

has an abrasion-resistant, non-porous work surface

has a solid work surface

is easy to clean

has lockable wheels

The work bench should be located close to the lifter, with space to allow trolleys to manoeuvre nearby.

Rollers

Rollers should be fitted to work benches to enable smooth transfer of instrument trays.

Transport trolley

When purchasing a transport trolley, ensure that it is compatible with the work environment, fit for purpose and:

shelving correlates to height adjustable workbench

where reasonably practicable, the trolley can be height adjusted

there is sufficient space to store instrument trays

is easily cleaned

has no sharp edges

Appendix 1: Process for suppliers - general information

To be easily maneuvered, the new surgical instrument transport cases (cases), described in the national guide Design and handling of surgical instrument transport cases (the guide), are designed to be securely stacked on a wheeled platform (or equivalent).

The design of tubs is not addressed within the scope of the guide. Tubs should only be used to transport prostheses and/or other lightweight surgical equipment not described in this guide. It is essential that tubs are loaded, unloaded and handled using appropriate manual handling techniques.

Loaded cases should remain on their platform at all times for ease of use and movement. For stability, heavier cases should be positioned lowest on the stack. Tubs can be placed on top of the stack of cases during handling and transport. The stack should not exceed 1350 mm in height and the combined weight of the stack should not exceed 80 kg.

The gross weight of each case and tub must be displayed.

When planning safe systems of work, you should consider the following:

1a. Plan the layout of the warehouse to allow for an efficient process flow, in particular the designated:

loan kit receipt area

loan kit processing area

loan kit despatch area

loan kit holding area, with designated space to store stacked empty cases (two to three high max) and empty tubs

instrument tray storage area

1b. Ensure the designated loan kit despatch and receipt areas are easily accessible to both workers and couriers.

2. It is recommended that suppliers encourage all couriers to avoid manual lifting during loading and unloading.

3. Ensure that all staff are trained in the relevant procedures and are competent to use any required equipment

Process for suppliers - despatch

Process

Consideration

1. Receive order

2. Pick loan kit

Shelving

Allow adequate space between shelving to allow unrestricted movement

Locate heavy and frequently used trays at waist height

Locate lighter trays on higher and lower shelves

Trolley/aid

Use a trolley/aid when picking equipment from warehouse shelving

Ensure the trolley/aid is height adjustable, or at individual’s waist height

Use appropriate manual handling techniques when handling trays.

3. Process order and pack loan kit

Slide trays onto workbench

Check trays against original order (follow QA procedures)

Ensure the correct number of cases/tubs are prepared for the order

Ensure cases are safely stacked and secured to wheeled platform/s, and that heaviest cases are positioned lowest in stack

Appendix 2: Process for couriers - general information

To be easily manoeuvred, the new surgical instrument transport cases (cases), described in the national guide Design and handling of surgical instrument transport cases (the guide), are designed to be securely stacked on a wheeled platform (or equivalent).

The design of tubs is not addressed within the scope of the guide. Tubs should only be used to transport prostheses and/or other lightweight surgical equipment not described in this guide. It is essential that tubs are loaded/unloaded and handled using appropriate manual handling techniques.

Loaded cases should remain on their platform at all times for ease of use and movement. Tubs can be placed on top of a stack of cases during handling and transport. The stack should not exceed 1350 mm in height and the combined weight of the stack should not exceed 80 kg. The gross weight of each case and tub must be displayed.

When deliveries consist of a single case only, appropriate manual handling principles must be adhered to (eg use a hand truck or similar).

Couriers should ensure:

their vehicles are fit for purpose

all loads are safely secured and restrained during transportation

mechanical aids, such as tailgate lifters or similar, should be fitted to the vehicle and, where this is not reasonably practical, appropriate aids (ie mobile lifters and ramps) should be used

the stacks are kept in their original configuration when delivered

Contractual arrangements covering the safe collection and delivery of kits should be in place with all parties. These arrangements should include:

designated vehicle loading and unloading areas

timely and effective despatch and receipt procedures

designated delivery and collection points

Process for couriers

Process

Consideration

1. Retrieve loan kit from despatch area

Park vehicle in designated loading zone or as close to hospital/supplier designated loan kit holding area as possible

Retrieve kits from designated area

Check total number of cases and tubs against documented order

Ensure each case is correctly locked and secured prior to leaving the designated holding area

Ensure tub lids are closed

Ensure all kits are appropriately labelled

Wheel kits to courier vehicle

Delivery route

When parking the vehicle, consider the ground/floor surface between the vehicle and pick up point at each destination

Have a set route (as direct as possible) between the vehicle and the pick up point at each destination

2. Load loan kits into courier vehicle

Load kits into the courier vehicle by means other than physically lifting

Ensure all kits are appropriately secured for travel in courier van

Courier equipment

The cases and platform are designed so that physical lifting and lowering of items is not required. It is recommended that any of the following aids are used to load and unload the stack/s into the vehicle:

tailgate lifter

a fixed, hydraulic fold out ramp

a set of lightweight skids

a lightweight portable, foldable ramp

a mobile lifter supplied by the supplier/ hospital

3. Unload loan kits from courier vehicle

Remove vehicle restraints

Ensure each case remains locked and secured to platform before unloading from vehicle

Unload kits out of vehicle by means other than physically lifting

4. Deliver loan kits to hospital/supplier

Park vehicle in designated area, or as close to the hospital/supplier designated loan kit area as possible

When parking the vehicle, consider the ground/floor surface between the vehicle and drop off point at each destination

Have a set delivery route (as direct as possible) between the vehicle and the drop-off point at each destination

Appendix 3: Process for hospitals - general information

To be easily maneuvered, the surgical instrument transport cases (cases), described in the national guide Design and handling of surgical instrument transport cases (the guide), are designed to be securely stacked on a wheeled platform (or equivalent).

The design of tubs is not addressed within the scope of the guide. Tubs should only be used to transport prostheses and/or other lightweight surgical equipment not described in this guide. It is essential that tubs are loaded, unloaded and handled using appropriate manual handling techniques.

Loaded cases should remain on their platform at all times for ease of use and movement. Tubs can be placed on top of a stack of cases during handling and transport. The stack should not exceed 1350 mm in height and the combined weight of the stack should not exceed 80 kg. The gross weight of each case and tub must be displayed.

When planning safe systems of work you should consider the following:

1a. Plan the layout of the loan kit area to allow for an efficient process flow, in particular the designated:

loan kit receipt area

loan kit processing area

loan kit despatch area

loan kit holding area, with designated space to store stacked empty cases (two to three high max) and empty tubs

instrument tray storage area

1b. Ensure the designated loan kit despatch and receipt areas are easily accessible to both workers and couriers.

2. Ensure that all staff are trained in the relevant procedures and are competent to use any required equipment

3. It is recommended that the hospitals encourage all couriers to avoid manual lifting during loading and unloading

4. It is recommended that internal/external processes are in place, to ensure equipment for routine elective surgery arrives at least 24 hours prior to the start of that surgery

Process for hospitals - receipt

Process

Consideration

1. Receive delivery from courier

Instruct courier to wheel kits to designated receipt area

Loan kit area

Ensure designated loan kit receipt area can be easily accessed by couriers and employees

1. Note: the above drawing shows a particular configuration, which includes a small case stacked on top of a large case. Other configurations may include three small cases or two large cases, provided the stack does not exceed 1350 mm in height.

2. Note: the above drawing shows a particular configuration, which includes a small case stacked on top of a large case. Other configurations may include three small cases or two large cases, provided the stack does not exceed 1350 mm in height.